Instructions:1. Please fill out the patient intake form below and submit it. 2. Check your email from DocuSign for important forms to sign. 3. Review, electronically sign and submit the forms to us. A representative from KC Primary Care will follow up with you shortly. Name(Required) First Last DOB(Required) Age(Required) Social Security Number(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Employer Gender(Required) Male Female Marital Status How Long? Pharmacy Phone In case of Emergency who to contact:Name Phone Please list Primary Physician(s) contact information:Physician/Facility Phone Please list medical concerns in order of importance (chief complaint #1):Medical History: Please check all that apply(Required) Arthritis Allergies (Hay fever) Asthma Alcoholism Blood Pressure Bronchitis Cancer Chronic Fatigue Syndrome Carpal Tunnel Syndrome Cholesterol-Elevated Circulatory Problems Colitis Dental Problems Depression Diabetes Diverticular Disease Emphysema Eyes, Ears, Nose Throat Environmental Sensitivities Fibromyalgia Gastroesophageal Reflux Glaucoma Gout Heart Disease Infection, Chronic Inflammatory Bowel Disease Irritable Bowel Syndrome Kidney or Bladder Disease Liver or Gallbladder Disease Migraine Headaches Neurological Problems Sinus Problems Stroke Obesity Osteoporosis Sexually Transmitted Disease Seasonal Affective Disorder Skin Problems Ulcer Urinary Tract Infections Varicose Veins Thyroid Other None Operations: Please include year of operationAppendectomy(Required) Yes No Appendectomy Year? Tonsillectomy(Required) Yes No Tonsillectomy Year? Prostate(Required) Yes No Prostate Year? Hysterectomy (partial or total)(Required) Yes No Hysterectomy (partial or total) Year? Cholecystectomy(Required) Yes No Cholecystectomy Year? Other(Required) Yes No Other Year? Preventative Care:Annual Physical Yes No Annual Physical Year? Mammogram Yes No Mammogram Year? Colonoscopy Yes No Colonoscopy Year? Bone Density Scan Yes No Bone Density Scan Year? Prostate Exam Yes No Prostate Exam Year? Labs Yes No Labs Year? Pap Smear Yes No Pap Smear Year? Last Menstrual Period Yes No Last Menstrual Period Year? Other Yes No Other Year? Allergies (please list): Please include reactionPlease list contact information for any physician(s) or facilities that have treated you for the condition that you are seeking treatment for (if applicable)…Physican/Facility: Phone Physican/Facility: Phone PHYSICAL HISTORY: PLEASE CHECK ALL THAT APPLY.Head Headaches-one sided Confusion, Brain Fog Blurred Vision Headaches-involves back of neck Dizziness, Unsteadiness Headaches-associated with light sensitivity Headaches-interfere with work Change in memory Other Select AllEyes Itching Glaucoma Sensitive to light Dryness Cataracts Corrective Lenses Puffy under eyes Dark circles Other Select AllEars Hearing Loss Drainage Ringing/Roaring Pain Other Select AllMouth and Throat Snore Wears dentures Neck glands swell Bad breath Hoarseness Difficulty swallowing Sore throats Grind teeth in sleep Other Select AllNose Itches Runs Blood streaked mucous Sneeze Requires nose drops/spray No sense of smell Sinus infection Other Select AllCardiac and Respiratory Wheeze Rapid heart beats Non-productive cough Ankle swelling Bronchitis Chest pains Skipped beats Short of breath Murmur Productive cough Cough up blood Night sweat Other Select AllGastrointestinal/Digestion: Heartburn Cramping Stomach aches Rectal bleeding Belching frequently Indigestion Mucous in stool Anal pain Diarrhea Blood in stool Nausea/Vomiting Bloating Excess gas Constipated Other Select AllUrinary and Genitalia: Frequent urination Kidney stones Yeast infection Unsatisfactory sexual relations Painful urination Weak stream Difficulty starting urination Burning Pass blood Genital herpes Lumps, pain swelling testicles Vaginal Dryness Painful Intercourse Irregular Bleeding Other Select AllEndocrine: Fatigue Heat intolerance Crave sugar Reaction time slowed down Feel puffy or swollen all over your body Sleepiness in the afternoon Light headed upon standing Difficult getting out of bed Deepening of voice Cold intolerance Crave salt Catch colds or infections easily Decreased libido Weight gain for no apparent reason Feel cold, chilled-hands, feet all over for no apparent reason Select AllMusculoskeletal: Muscle weakness Morning stiffness Back pain Numbness/tingling of hands and feet Muscle cramps Joint swelling, pain or stiffness Increased redness, warmth of joint Decreased strength Muscle twitching Parts of the body feel tender, sore, sensitive to touch Other Select AllSkin: Eczema Easy bruising Brittle nails Hives Dry skin Rash Oily Other Select AllPsychological: Often unhappy Difficulty falling asleep Misunderstood by others Unable to concentrate Use tranquilizers Considered a nervous person Easily flare in anger Frequently keyed up and jittery Am a workaholic Extremely shy or sensitive Difficulty staying awake Other Select AllPhysical History:Please list any prescription medications, OTCs (over the counter medications), vitamins, minerals, supplements you are taking. Please list the amounts (i.e. 500 mg tablet 2x/day), when you take them (schedule) and why you are taking them.Social History:Children(Required) Yes No How Many? Cigarretes(Required) Yes No How much /day? How many years? Cigars(Required) Yes No How many /day? week? Chewing Tobacco(Required) Yes No How many /day? week? Alcohol(Required) Yes No How many /day? week? Coffee(Required) Yes No How many /day? week? PMI/FH: HAVE YOUR FAMILY MEMBERS HAD ANY OF THE PROBLEMS LISTED BELOW?Alcoholism Yes Who among the family members?MotherFatherGrandparentsSiblingsChildrenAnemia Yes Who among the family members?MotherFatherGrandparentsSiblingsChildrenArthritis Yes Who among the family members?MotherFatherGrandparentsSiblingsChildrenAsthma Yes Who among the family members?MotherFatherGrandparentsSiblingsChildrenCancer Yes Who among the family members?MotherFatherGrandparentsSiblingsChildrenDiabetes Yes Who among the family members?MotherFatherGrandparentsSiblingsChildrenEmphysema Yes Who among the family members?MotherFatherGrandparentsSiblingsChildrenHeart Disease Yes Who among the family members?MotherFatherGrandparentsSiblingsChildrenHigh Blood Pressure Yes Who among the family members?MotherFatherGrandparentsSiblingsChildrenOsteoporosis Yes Who among the family members?MotherFatherGrandparentsSiblingsChildrenMental Illness Yes Who among the family members?MotherFatherGrandparentsSiblingsChildrenThyroid Disorders Yes Who among the family members?MotherFatherGrandparentsSiblingsChildrenOtherREAD THOROUGHLY BEFORE SUBMITTINGPATIENT ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE I hereby acknowledge receipt of the Notice of Privacy Practices for KC Primary Care regarding my health information. I have been informed and understand the manner in which my health information shall be maintained, utilized and disclosed by Clinic and my respective rights contained there in. I also understand that the Notice furnished to me is subject to change at any time. I am aware that I may obtain a current copy of this Notice at any time by contacting KC Primary Care, 1412 NW Vivion Road Kansas City, MO 64118. CONSENT TO TREAT I hereby authorize the Doctor’s to treat my case as they deem appropriate.Name(Required) First Middle Last Date(Required) Month Day Year CAPTCHANameThis field is for validation purposes and should be left unchanged.